Clin Rheumatol (2013) 32:325–331
DOI 10.1007/s10067-012-2117-y
ORIGINAL ARTICLE
Assessment of the relationship between postural stability
and sleep quality in patients with fibromyalgia
Nuray Akkaya & Semih Akkaya & Nilgun Simsir Atalay &
Merve Acar & Necdet Catalbas & Fusun Sahin
Received: 11 June 2012 / Revised: 18 October 2012 / Accepted: 28 October 2012 / Published online: 21 November 2012
# Clinical Rheumatology 2012
Abstract The aim of this study is to investigate the rela-
tionship of postural stability and sleep disorders in patients
with fibromyalgia syndrome. Frequency of falls in the last
6 months in 48 fibromyalgia and 32 control subjects were
recorded. Postural stability was assessed by static posturog-
raphy device (Tetrax, Sunlight Medical Ltd., Israel). Func-
tional assessment consisted of lower-body strength; one-leg
stance test were applied to all subjects. Fibromyalgia impact
questionnaire (FIQ), sleep quality numeric rating scale
(NRS), and Pittsburgh Sleep Quality Index were inquired.
The number of falls in the last 6 months was significantly
higher in the fibromyalgia group. Mean total value of sta-
bility indexes was 201.7±70.9 vs. 162.6±29.6 in fibromy-
algia and control subjects (p<0.05). NRS and Pittsburgh
Sleep Quality Index were significantly higher in fibromyal-
gia patients. It was detected that there were significant
relationships between fall risk and NRS scores (r00.565),
and FIQ fatigue subscores (r00.560) (both p<0.05). Worse
postural performance and fall risk found in the fibromyalgia
patients compared to controls were related with the sleep
quality in the last 24 h and level of fatigue.
Keywords Fatigue . Fibromyalgia syndrome . Postural
stability . Sleep quality
N. Akkaya (*) : N. S. Atalay : N. Catalbas : F. Sahin
Department of Physical Medicine and Rehabilitation, Pamukkale
University Medical School, 20210 Kınıklı Denizli, Turkey
e-mail: nrakkaya@gmail.com
S. Akkaya
Department of Orthopedics and Traumatology, Pamukkale
University Medical School, 20210 Kınıklı Denizli, Turkey
M. Acar
Department of Physical Medicine and Rehabilitation, Denizli
Government Hospital, Bayramyeri Denizli, Turkey
Introduction
Fibromyalgia syndrome (FMS) is a chronic widespread pain
syndrome, with the main symptoms are fatigue, depression,
and sleep disorders [1]. Although the most striking symp-
tom is pain, other sensorimotor functions might also be
affected from the abnormal central processes [2].
Balance, or postural stability, is a complex task that
involves the integration of multiple sensory inputs to exert
appropriate neuromuscular activity required to maintain the
balance. In a study of 2,596 fibromyalgia patients, 45 % of
them had balance problems, and these balance problems
were among the first ten common symptoms [3]. A recent
study demonstrated increased postural instability and in-
creased frequency of fall in FMS patients [4].
Abnormal pain processing by the central nervous system
is thought to lead to increased pain and fatigue, as well as to
the deterioration of proprioceptive inputs from painful
muscles to the central nervous system, and increased fall
risk due to sleep disturbance-related postural instability in
FMS patients [2, 5]. It was suggested that postural stability
which includes multiple neural subsystems might be affect-
ed in FMS, and fatigue, decreased flexibility, and greater
body mass index may have a role in postural instability [4].
It is well known that fatigue-induced cognitive dysfunc-
tion and sleep disturbances have negative impacts on bal-
ance in healthy people [6, 7]. Restless sleep, non-REM sleep
disturbances, and fatigue are common symptoms of FMS
[8]. Although the relationship of sleep disorders and postur-
al instability is well studied in healthy people [6, 7], it has
not been studied in FMS, in which sleep disorders and
postural instability are common.
The aim of the study was to compare the static postural
stability and fall risk between FMS patients and control
subjects, as well as to investigate the relationships of the
static postural stability, sleep quality, and functional status.
326
Material and methods
Patients who had diagnosis of FMS, between 20–
50 years of age, were identified from our outpatient
records in the last 1 year. Patients were informed about
the study by phone call. Age-matched (20–50 years of
age) control subjects were healthy relatives of the hos-
pital staff. The study was approved by the local Human
Ethics Committee, and written informed consent was
obtained from each participant.
Exclusion criteria for both of the fibromyalgia and con-
trol groups were a history of an inflammatory rheumatic
disease or an inner ear disease, the use of antidepressant,
opioid, or sedative drugs, previous or current vertigo or
dizziness, an apparent visual loss, orthopedic problems in
lower extremities, or previous orthopedic surgery, neurolog-
ical disorder, or peripheral neuropathy.
Demographic features (age, body mass index, education,
and occupation), duration of FMS symptoms, and number
of FMS tender points of the FMS patients and control
subjects fulfilling the inclusion criteria and accepting to
participate the study were recorded. Patients were asked to
mark the FMS symptoms (sleep disturbances, paresthesia,
morning stiffness, fatigue, headaches, dysmenorrhea, irrita-
ble bowel syndrome, and female urethral syndrome) as
present or absent.
The number of falls in the last 6 months in FMS patients
and control subjects was asked to subjects and recorded.
Posturographic analysis of FMS patients and control sub-
jects were performed by Tetrax Interactive Balance System
(Sunlight Medical Ltd., Israel) at the same time of the day
(at 11:00 a.m.) and by the same technique which is directed
by the user’s guide of the device. Tetrax static posturogra-
phy device has a computer and software system, and all the
data obtained from the device were the results of the soft-
ware. The device measures vertical pressure fluctuations on
four independent stable platforms, each placed beneath the
two heels and toe parts of the subject; inputs from these
platforms are integrated and processed by a computer digi-
tally. Before the task, the patients were instructed to place
their feet side by side on lined places of the platform in
shape of feet, not to speak and move during the task.
Measurements are made in eight different positions in all
subjects with the same technique, sequence, and directions
(each position takes about 40 s): (1) head straight, eyes
open, on a hard ground; (2) head straight, eyes closed, on
a hard ground; (3) head straight, eyes open, on a soft ground
(sponge under feets); (4) head straight, eyes closed, on a soft
ground; (5) head turned to the right, eyes closed, on a hard
ground; (6) head turned to the left, eyes closed, on a hard
ground; (7) neck fully extended, eyes closed, on a hard
ground; and (8) neck fully flexed, eyes closed, on a hard
ground [9, 10].
Clin Rheumatol (2013) 32:325–331
Data obtained from the software of Tetrax Interactive
System are the following: (1) Fall risk calculated by con-
sidering the oscillation velocities computed by posturo-
graphic software was recorded for all the subjects [9, 10].
Fall risk is a numeric value from 0 to 100, with three
numerical ranges 0 to 35, 36 to 57, and 58 to 100, indicating
low, moderate, or high risk of fall, respectively [11, 12]. (2)
General stability index based on the assessment of replace-
ment of gravity center from each of the four platforms.
General stability indexes obtained from 8 different positions
were calculated for total general stability index. Higher
scores of total general stability index imply a worse postural
performance. (3) Fourier transformations that comprise
four independent wave signals and subdivided into eight
band frequencies (0.01 to 0.1, 0.1 to 0.25, 0.25 to 0.35,
0.35 to 0.5, 0.5 to1, 1 to 3, and 3 Hz and more) were
recorded in all patients and control subjects. Fourier fre-
quencies from 0.01 to 0.1 Hz are classified as low frequen-
cies (F1), which are related to visual control, and associated
with a normal position and comfortable posture. Frequen-
cies from 0.1–0.5 Hz are classified as medium-low frequen-
cies (F2–4), which are sensitive to vestibular stress and
disturbances. Frequencies from 0.5–1 Hz are classified as
medium-high frequencies (F5–6), which reflect somatosen-
sory activity and postural reflexes from the lower extremi-
ties. Frequencies higher than 1 Hz (F7–8) cause from
dysfunction of central nervous system. Lower standard
errors in Fourier frequencies imply a better postural
performance [13].
Functional status was assessed by lower-body muscle
strength and standing on one-leg stance test. Lower-body
muscle strength was assessed on the subject sitting on a
chair and crossing arms over the chest who is asked to
perform as many stands from a sitting position as possible
in 20 s; the total number of stands executed correctly is used
as the recorded value. Higher values indicate better lower-
body strength. Applying the one-leg stance test, the subject
is asked to stand on the dominant leg with closed eyes for as
long as possible while the knee of the non-dominant side is
fully flexed, the leg is fixed on the gluteal region by the
ipsilateral hand, and the hip and knee of the dominant side is
extended. The total length of time the subject can stay in the
balance position is recorded. When the subject losts her
balance position, she is allowed to touch her foot to the
ground. After each break, the same position is repeated until
completing the 30 s of one-leg stance test, and the total
length of time in balance position is recorded. The
number of the test repeats with a duration of 30 s is
used as the recorded value, and higher values indicate
the worse results [14].
Fibromyalgia impact questionnaire (FIQ) was used to
assess the impact of FMS on functional status and quality
of life. FIQ is a self-administered instrument with three main
Clin Rheumatol (2013) 32:325–331
topics (function, overall effect of the disease, and symp-
toms) that assess the physical function, job status, depres-
sion, anxiety, sleep, pain, stiffness, fatigue, and well-being.
It assesses the impact of FMS on patients for the last 7 days,
and higher scores indicate that the syndrome has a greater
impact on the patient [15]. Total scores and fatigue sub-
scores of FIQ were examined in the present study for both
FMS patients and control cases. Fatigue subscore of FIQ is a
score from 0 to 10, with higher scores indicating more
intense fatigue. Sleep quality and sleep disorders were
assessed by sleep quality numeric rating scale and Pitts-
burgh Sleep Quality Index for both FMS patients and con-
trol cases. Sleep quality numeric rating scale assesses the
quality of sleep in the last 24 h on a numeric rating
scale ranging from 0 (“best possible sleep”) to 10
(“worst possible sleep”) [16].
Pittsburgh Sleep Quality Index is an effective instrument
used to measure the quality of sleep, to identify sleep dis-
orders, and to differentiate the subjects with sleep disorders
from the healthy subjects. Pittsburgh Sleep Quality Index
includes a total of 24 questions, with 18 of them are self-
rated and 5 are bed partner or roommate rated; the other
question is about if the subject has a roommate. The latter
six questions are not used in the scoring scale; they are
rather used for obtaining clinical information. The self-
rated 18 questions measure seven areas of the sleep: subjec-
tive sleep quality, sleep latency, sleep duration, habitual
sleep efficiency, sleep disturbances, use of a sleeping med-
ication, and daytime dysfunction. Scoring of answers is
based on a 0 to 3 scale, which has a range of 0–21, with
higher scores indicating worse sleep quality. A total Pitts-
burgh Sleep Quality Index score of ≥5 indicates a poor sleep
quality [17].
Statistical procedures were performed using SPSS 17.0
software. Student’s t test was used to compare the numeric
data between groups, and chi-square test to compare the
categorical variables (p values less than 0.05 were consid-
ered significant). Correlation analyses were used to examine
the associations between the independent variables and
fall risk in the fibromyalgia group, by Pearson correla-
tion test (r) values.
Results
Sixty-three FMS patients were identified from the last
1 year’s outpatient records, two of them were lost, five
refused to participate the study, two with a diagnosis of
neurological disease (peripheral neuropathy), and six with
a current or previous vertigo were excluded from the study.
Forty-eight FMS patients and 32 control subjects, with a
mean age of 35.9±10.1 years and 33.2±7.9 years and a
mean body mass index of 27.8±4.5 and 25.8±5.3 kg/m2,
327
respectively, were included to the study. All of the patients
and control subjects were female. Fifteen (31.2 %) FMS
patients were primary/secondary school graduates, 33
(68.8 %) were high school/college graduates, 21 (43.8 %)
were housewives, 12 (25 %) were officers, and 15 (31.2 %)
were workers compared to 7 (31.8 %), 25 (78.1 %), 11
(34.4 %), 12 (37.5 %), and 9 (28.1 %) of control subjects,
respectively. There was no significant difference between
the two groups in education level and occupation (p>0.05).
Mean duration of the symptoms was 34.4±26.9 months, and
mean number of the FMS tender points was 14.7±2.5 in
FMS patients.
In terms of FMS symptoms, 42 (87.5 %) of FMS
patients and 4 (12.5 %) of control subjects had sleep
disturbances (p <0.05). Paresthesia was present in 32
(66.7 %) and 2 (6.3 %), stiffness in 33 (68.8 %) and
1 (3.1 %), fatigue in 48 (100 %) and 10 (31.3 %),
anxiety in 44 (91.7 %) and 2 (6.3 %), headache in 43
(89.6 %) and 7 (21.9 %), dysmenorrhea in 24 (50 %)
and 5 (15.6 %), irritable bowel syndrome in 29
(60.4 %) and 1 (3.1 %), depression in 37 (77.1 %)
and 3 (9.4 %), and female urethral syndrome in 25
(52.1 %) and 1 (3.1 %) of FMS patients and control
subjects, respectively. All fibromyalgia symptoms were more
frequent in the FMS group than the control group (p<0.05).
Mean number of falls in the last 6 months was signifi-
cantly higher in the FMS group compared to the control
group (0.8±1.4 vs. 0.1±0.2, p<0.05). Fall risk was signif-
icantly higher in the FMS group compared to the control
group (46.9±24.9 vs. 26.3±14.8, p<0.05). Total general
stability index was 201.7 ± 70.9 and 162.6 ± 29.6 in the
FMS and control groups, respectively (p<0.05).
Analysis of Fourier frequencies presented a significant
difference between groups in favor of the control group for
F2–4 frequency (low frequency, related to vestibulary dis-
tress and disturbance) in all of the positions, except for the
position of head straight, eyes open, on a hard ground. F5–6
frequency (medium-high frequency, related to somatosenso-
rial activity and lower extremity-associated postural
reflexes) was significantly different between groups in favor
of the control group in the positions of head straight, eyes
closed, on a hard ground; head turned to the left, eyes
closed, on a hard ground; and neck fully flexed, eyes
closed, on a hard ground (p<0.05) (Tables 1 and 2,
only significant differences for the distribution of Four-
ier frequencies are presented).
Lower-body muscle strength and one-leg stance test were
significantly worse in the FMS group compared to the
control group (p<0.05, Table 3). FIQ total score, FIQ fa-
tigue subscore, and scores of sleep quality numeric rating
scale and Pittsburgh Sleep Quality Index were significantly
higher in the FMS group compared to the control group
(p<0.05, Table 3).
328 Clin Rheumatol (2013) 32:325–331

Table 1 Distribution of patients at Fourier 2–4 frequencies in positions in which significant difference was detected between groups

Fourier frequency (F2–4) Standard deviation Fibromyalgia (n (%)) Control (n (%)) p value
n048 (n032)

Head straight, eyes closed, on a hard ground 1.0–1.5 20 (41.7) 23 (71.9) 0.020*
1.5–3.0 13 (27.1) 7 (21.9)
3.0–6.0 8 (16.7) 2 (6.3)
>6.0 7 (14.6) 0
Head straight, eyes open, on a soft ground 1.0–1.5 24 (50) 29 (90.6) 0.002*
1.5–3.0 14 (29.2) 1 (3.1)
3.0–6.0 8 (16.7) 2 (6.3)
>6.0 2 (4.2) 0
Head straight, eyes closed, on a soft ground 1.0–1.5 17 (35.4) 25 (78.1) 0.001*
1.5–3.0 10 (20.8) 6 (18.8)
3.0–6.0 13 (27.1) 1 (3.1)
>6.0 8 (16.7) 0
Head turned to the right, eyes closed, on a hard ground 1.0–1.5 11 (22.9) 14 (43.8) 0.008*
1.5–3.0 12 (25) 12 (37.5)
3.0–6.0 14 (29.2) 6 (18.8)
>6.0 11 (22.9) 0
Head turned to the left, eyes closed, on a hard ground 1.0–1.5 17 (35.4) 17 (53.1) 0.039*
1.5–3.0 9 (18.8) 10 (31.3)
3.0–6.0 13 (27.1) 4 (12.5)
>6.0 9 (18.8) 1 (3.1)
Cervical extension, eyes closed, on a hard ground 1.0–1.5 11 (22.9) 18 (56.3) 0.001*
1.5–3.0 11 (22.9) 10 (31.3)
3.0–6.0 15 (31.3) 3 (9.4)
>6.0 11 (22.9) 1 (3.1)
Cervical flexion, eyes closed, on a hard ground 1.0–1.5 17 (35.4) 18 (56.3) 0.005*
1.5–3.0 13 (27.1) 13 (40.6)
3.0–6.0 12 (25) 0
>6.0 6 (12.5) 1 (3.1)

F Fourier frequency derived from the software of Tetrax

*p<0.05

Table 2 Distribution of patients at Fourier 5–6 frequencies in positions in which significant difference was detected between groups

Fourier frequency (F5–6) Standard deviation Fibromyalgia (n (%)) Control (n (%)) p value
(n048) (n032)

Head straight, eyes closed, on a hard ground 1.0–1.5 25 (60.4) 30 (93.8) 0.009*
1.5–3.0 11 (22.9) 2 (6.3)
3.0–6.0 5 (10.4) 0
>6.0 3 (6.3) 0
Head turned to the left, eyes closed, on a hard ground 1.0–1.5 23 (47.9) 22 (68.8) 0.047*
1.5–3.0 12 (25) 9 (28.1)
3.0–6.0 10 (20.8) 1 (3.1)
>6.0 3 (6.3) 0
Cervical flexion, eyes closed, on a hard ground 1.0–1.5 25 (52.1) 28 (87.5) 0.010*
1.5–3.0 16 (33.3) 2 (6.3)
3.0–6.0 6 (12.5) 2 (6.3)
>6.0 1 (2.1) 0

F Fourier frequency derived from the software of Tetrax

*p<0.05
Clin Rheumatol (2013) 32:325–331 329

Table 3 Comparison of lower-body strength, one-leg stance test, fibromyalgia impact questionnaire, fibromyalgia impact questionnaire fatigue
subscore, and scores of sleep quality scales between groups

Fibromyalgia group (n048) Control group (n032) p value

Lower-body strength 9.9±1.7 13.2±2.7 0.001*

One-leg stance test 7.8±2.5 2.9±1.7 0.001*
FIQ 70.5±13.4 10.4±9.8 0.001*
FIQ fatigue 5.5±2.2 0.8±0.9 0.001*
Sleep quality numeric rating scale 4.7±1.8 2.1±2.4 0.001*
Pittsburgh Sleep Quality Index 10.8±4.4 4.2±3.2 0.001*

FIQ fibromyalgia impact questionnaire

*p<0.05

In the FMS group, significant relationships were Quality Index in the control group (p>0.05). Also, there was
detected between fall risk and the number of falls in no significant relationship between sleep quality in the last
the last 6 months (r00.397), one-leg stance test (r00.416), 24 h and FIQ fatigue subscore for the control group (p>0.05).
FIQ fatigue subscore (r00.560), sleep quality numeric rating
score (r00.565), and lower-body muscle strength (r0−0.578)
(p<0.05). When the relationship between sleep and fatigue Discussion
was examined, a significant relationship was found between
the sleep quality in the last 24 h, and FIQ fatigue subscore Results of the present study revealed that postural perfor-
(r00.666) (p<0.05, Table 4). mance is worse in FMS patients compared to the control
There were no significant relationships between fall risk subjects and that postural performance is related to the
and the duration of pain, the number of fibromyalgia tender severity of fatigue and sleep quality in the last 24 h, with
points, FIQ total score, and Pittsburgh Sleep Quality Index disturbances in these parameters negatively affecting the
in the FMS group (p>0.05, Table 4). Fall risk was not postural performance in fibromyalgia patients, but not in
significantly related to the number of falls in the last control subjects.
6 months, lower-body muscle strength, one-leg stance test, There are several studies demonstrating an impaired pos-
FIQ total score, FIQ fatigue subscore, and Pittsburgh Sleep tural balance and increased fall risk in FMS patients. Russek
and Fulk [2] studied 32 FMS patients with the use of
Activity-specific Balance Confidence Scale, Berg Balance
Table 4 Relationships between fall risk and clinical variables for the
fibromyalgia group test, NeuroCom Balance Master Sensory Organization Test,
and limits of stability. The authors reported that postural
p value Pearson control was impaired in FMS patients and that this impair-
correlation
coefficient (r)
ment might be related to impaired sensory processing of the
postural inputs. Russek and Fulk [2] suggested that the
Fall risk and duration of pain 0.106 0.236 results of their study support the assumption of impaired
Fall risk and number of 0.909 −0.017 central processing of vestibular inputs in FMS patients.
fibromyalgia tender points In our study, both somatosensorial reflex- and postural
Fall risk and number of falls 0.005* 0.397 reflex-related Fourier frequencies (F5–6) in the positions
in the last 6 months
Fall risk and lower-body strength 0.001* −0.578 on a hard ground with eyes closed and head straight,
Fall risk and one-leg stance test 0.003* 0.416 head turned to the left, or neck flexed, as well as
Fall risk and FIQ 0.919 0.015 vestibulary system-related Fourier frequencies (F2–4) in
Fall risk and FIQ fatigue 0.001* 0.560 all of the positions except for the position on a hard
Fall risk and sleep quality in the 0.001* 0.565
ground with eyes open and head straight were signifi-
last 24 h cantly different in FMS patients compared to the control
Fall risk and Pittsburgh Sleep 0.458 0.110 subjects. However, given that the present study did not
Quality Index evaluate the function of the vestibular system with specific
Sleep quality in the last 24 h 0.001* 0.666
and FIQ fatigue
tests, the results could not determine whether the differences
found in the vestibular components of Fourier frequencies
FIQ fibromyalgia impact questionnaire result from the peripheral deficiency or from the defective
*p<0.05 central processing.
330
Limited number of studies reported autological disorders
that can cause vestibular dysfunction in FMS patients. One
of these studies found that tinnitus, hearing loss, and dizzi-
ness are the most common symptoms of FMS patients
following vertigo [18]. Auditory brainstem responses were
found to be abnormal in 31 % of FMS patients, and it was
suggested that the brainstem may play an important role
not only in eye movements and auditory function but
also in muscle synergy and multisensory integration for
the postural control [19].
In a study examining the balance by Balance Evaluation-
Systems Test, Activities-specific Balance Confidence Scale,
and the number of falls in the last 6 months in 34 FMS
patients and 32 age-matched control subjects, a balance
disturbance was established in FMS patients, and increased
number of falls was found in FMS patients compared to the
control subjects [4]. The authors concluded that both the
central and peripheral components of balance could be
affected in FMS patients. They also stated that balance
disturbance may be related to the vestibulary function, pro-
prioception, spatial–visual orientation, deficits of muscle
strength or postural reflexes, orthostatic blood pressure dys-
function, or attention deficits. Although patients with dizzi-
ness, a previous head trauma, vestibular problems, or
peripheral neuropathy were excluded from the study, they
denoted that there may be some deficits with no clinical
symptoms. We also excluded patients with similar problems
and found a worse postural performance and a higher fall
risk in FMS patients.
Tomas-Carus et al. [14] randomly assigned 30 FMS
patients to an exercise therapy group (n015) and a control
group (n015) and evaluated the effects of the exercise therapy
on muscle strength by isokinetic knee extensor and flexor
testing, on the quality of life by Short Form-36, and on
postural balance by one-leg stance test. The authors reported
that 32 months of exercise in warm water resulted in signifi-
cant improvements in muscle strength, quality of life sub-
scores and balance, and that excentric knee extensor muscle
strength gain was a determining factor for the improvement of
postural balance. Isokinetic testing was not included to the
present study, but the strength of the lower extremity was
assessed by sit-to-stand test. Fall risk was found to be related
to lower-body strength and scores of one-leg stance test.
In addition to the suggested mechanisms for balance
disturbance in FMS patients, balance was evaluated in
healthy subjects before and after 24 h of sleeplessness
period, and it was reported that fatigue due to sleeplessness
can affect the postural stability [7]. The authors of that study
also reported that objective posturographic test score can
identify mental fatigue objectively [7]. Given that FMS is a
chronic disorder associated with widespread pain, non-REM
sleep disturbances, and restless sleep, postural balance dis-
turbances can be expected. However, the literature is lacking
Clin Rheumatol (2013) 32:325–331
about the relationship of postural balance disturbances with
sleep disturbances in FMS patients. The present study
revealed that postural performance of FMS patients is worse
than the healthy control subjects, and sleep quality in the last
24 h and postural stability are related to FIQ fatigue sub-
scores. However, the questionary for the last month sleep
quality is not related to fall risk and postural stability. As to
healthy control subjects, there were no relationships be-
tween functional status, fatigue severity, or sleep quality.
These can be attributed to the fact that because of not
generating the sleeplessness model in healthy control sub-
jects, it is possible that postural performance and sleep
disturbance could not be evident. Thus, no clear-cut con-
clusions can be drawn.
It was reported that several drugs can disturb the balance
and are related to falls [20]. Many drugs including muscle
relaxants, antidepressant drugs, or opioids, which can be
used commonly by FMS patients, can contribute to balance
disturbances in these patients. Jones et al. [4] reported that
44 to 74 % of their FMS patients were using such drugs.
There were no patients receiving opioids, and patients
receiving antidepressant drugs were excluded from the
present study.
There are some limitations of the present study. Firstly,
objective assessment of the balance was performed by static
posturography, but not by dynamic posturographic tests,
which can reveal discrepant results. Secondly, FMS patients
and control subjects with a current or previous vestibulary
system problem were excluded from the study, but they
were not evaluated by audiological tests. If these tests were
used, exclusion of the patients and control subjects might be
more objective. However, these tests would be troublesome
especially for healthy control subjects. Thirdly, sleep quality
of the FMS patients and control subjects were assessed by
questionnaires based on self-reporting. However, if the sleep
quality was assessed in a sleep laboratory, the results might
be more objective. Although balance problems were
reported and several accountable mechanisms were pro-
posed in FMS patients, there are no studies investigating
the possible balance-related factors such as lower-body
muscle strength, as well as mental fatigue related to the
sleep quality in these patients. Thus, despite the limitations
of the present study, it is the first that investigates the above-
mentioned relationships and may guide the future studies.
The results of the present study revealed that postural per-
formance is disturbed, and balance is related to the sleep quality
in the last night in FMS patients. In addition, even in the
absence of vestibulary symptoms, vestibulary system disorders
could be detected in static balance tests in FMS patients. Dis-
orders of somatosensorial and postural reflexes also might
contribute to the balance disturbance. In conclusion, there is
no single mechanism that can account for postural stability
disturbances in FMS patients. Identification of balance-related
Clin Rheumatol (2013) 32:325–331
factors in FMS patients would be useful to prescribe the med-
ical treatment and the exercise programs, as well as would
ensure a more holistic approach to the treatment.
Disclosures None.
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